R L Evans Company - Regence Enrollment

Regence Enrollment

Eligibility

To be eligible you must not be eligible for Medicare and be a resident of one of the following counties; Clallam, Columbia, Cowlitz, Grays Harbor, Island, Jefferson, King, Kitsap, Klickitat, Lewis, Mason, Pacific, Pierce, San Juan, Skagit, Skamania, Snohomish, Thurston, Wahkiakum, Walla Walla, Whatcom or Yakima.

Eligible dependents include your spouse and children under age 25 who are primarily dependent upon you for support. Dependents age 25 or older may apply as members for their own plan coverage.

Enrollment Forms & Instructions

Completed enrollment materials must be received in Regence's office by 5:00 on the last business day of the month to be considered for an effective date of the first of the following month.

Complete the Regence’s Enrollment Application orApply Online. Only one application is necessary per family and we recommend that you complete the Regence SurePay Form so that premium payments are not missed by accident.
If you are enrolling a domestic partner, please complete the Domestic Partner Affidavit and return with the enrollment form.
Complete the Standard Health Questionnaire. A separate questionnaire must be completed for each enrolling family member unless:
- Relocation: Applicant is applying within 90 days of having relocated within Washington State and the prior health plan is not available. Include a copy of a utility bill in your name from the prior address and a letter of verification from your prior carrier.
- Provider Cancellation: Applicant’s health care provider left prior plan’s network therefore applicant is applying within in 90 days to a carrier that the provider is participating. Include a letter of verification from the provider or carrier.
- COBRA Exhaustion: The applicant has exhausted all COBRA continuation coverage and is applying within 90 days of COBRA ending or youlost coverage due to your employer going out of business or discontinuing its health plan while on COBRA. Include a letter from the COBRA Administrator verifying that you have exhausted your COBRA benefits.
- Employer’s Plan Not Subject to COBRA: Applicant is applying within 90 days of losing coverage under an employer’s plan that was not subject to COBRA coverage and you had at least 24 months of continuous group coverage before such loss. Include a letter of verification from the employer.
- COBRA Termination: Applicant is applying within 90 days of terminating COBRA coverage and had at least 24 months of continuous group coverage prior to termination. Include a letter of verification from the employer and certificate of coverage.
- COBRA Eligible – Applicant is applying within 90 days of an event which qualifies you for COBRA and you had at least 24 months of continuous group coverage prior to such event but you chose not to take COBRA coverage. Include a letter of verification from your employer addressing your COBRA eligibility and a certificate of coverage for proof of 24 months of continuous coverage.
- Loss of Basic Health Plan (BHP) Coverage: Applicant is applying within 90 days of losing coverage under the BHP and had at least 24 months of continuous BHP coverage before such loss. Include a letter of verification from the BHP.
- Addition of Newborn: Applicant is adding a newborn or newly adopted child to an existing policy within 60 days of birth, adoption or date of placement for adoption. Include copy of birth certificate/adoption papers.
Submit your Enrollment Application and Standard Health Questionnaire to: